The convoluted nature of the NHS’s national oversight is the product of the bungled Lansley reforms.
However, despite almost universal desire to change the statutory footing of the service, new legislation to sort the mess might not arrive until 2023.
Under most scenarios, the current dog’s dinner will be with us for the foreseeable future.
The proposals to integrate the work of NHS England and NHS Improvement – revealed yesterday – need to be seen in the context of the prime minister’s commitment to a long term plan and multi-year funding settlement for the service.
This is not simply a tactical attempt to get a better grip on overspending trusts (though it might help do that). It is a strategic bid to create a sustainable management structure to deliver that new plan. In other words, it matters a lot more than your usual shuffling of the NHS deckchairs.
The integration should be judged on its success in creating the right incentives, enabling the information the system needs to operate effectively and clarifying the decision rights of the various players.
There are areas where the law prevents integration. The organisations still need to have separate chairs and chief executives, and they will probably continue to have dedicated national finance directors for some time.
The logic for merging the great majority of the remaining top national posts is likely to trump inertia relatively quickly.
It will matter whether Simon Stevens and Ian Dalton can successfully re-engineer the Heath Robinson machine they inherited
At regional level, the decision to merge lead director and finance director posts is already made, and it is the latter that is most telling.
A single finance director will surely produce integrated balance sheets for each region – a powerful tool in reducing local arm wrestles between commissioners and providers and, the centre hopes, a force for financial discipline. Just as importantly, it will focus regional managers on getting providers and clinical commissioning groups working together.
Improved information flowing to healthcare economies should be one of the quickest of wins from better joint working. NHSI could well take NHS England’s Right Care programme and put it alongside Getting It Right First Time and the model hospital to produce a joined up view of what good looks like.
Common datasets and conventions, together with joined up incentives, may help address the dire state of activity planning - giving a more realistic view of demand, helping providers to make better calls on expected activity and the required capacity to service it.
Of course, there is plenty of scope for this welcome attempt by NHSE and I to act as one to come unstuck.
Simon Stevens and Ian Dalton will have to be very clear with their joint reports and each other about who takes the lead on what. The pair have complimentary skills and interests – so there is a possibility the new approach might address both organisations’ internal challenges. But it will be delicate, day to day balancing act.
More significantly, both organisations could fall foul of the fate that befell NHSI as it was created from Monitor and the NHS Trust Development Authority – another “non-merger” that nevertheless gobbled up senior time and effort.
NHS England and NHSI face stringent budget cuts, which will mean redundancies. These will be conflated with the joint working proposals, prompting suspicion and an understandable preoccupation with personal survival.
Should the NHS win a game changing funding settlement on or near its 70th birthday, there will be few concerns about the shape of national NHS management among the celebrations.
As it turns to work on spending the cash in the right way, it will matter whether Mr Stevens and Mr Dalton can successfully re-engineer the Heath Robinson machine they inherited to lead the service into the next decade.